Kate Sheehan highlights the importance of keeping clear and concise records for everyone you treat

The Health and Care Professions Council (HCPC) requires you to ‘keep full, clear, and accurate records for everyone you care for, treat, or provide other services to”, and that “you must complete all records promptly and as soon as possible after providing care, treatment or other services”. 

So, what constitutes a ‘care record’? According to The Data Protection Act 1998, it refers to a care record as any record which:

  1. consists of information relating to the physical or mental health or condition of an individual, and
  2. has been made by or on behalf of a healthcare professional in connection with the care of that individual.

They are critical for many reasons, including continuity of care for an individual patient/client, thus must be clear, concise and evidence-based, supporting fellow colleagues to understand the interventions and allow them to carry on day-to-day care, to meet your employers standards of practice, to meet legal duties and to enable audits and learn from good and poor documentation, to name but a few.

Importantly it is a tool we can use to indicate our core professional requirement of putting the client at the centre of everything we do, to show we are giving our clients choice and control over how services are provided to them, recording where this has not been achievable and how this could be changed in the future.

Do we take them seriously? 

The HCPC can and does take action against occupational therapists who fall below their standards of conduct and it is one of the top reasons for HCPC registrants being struck off, yet do we take it seriously and why is it so vital that we keep clinical notes?

Having reviewed a number of clinical notes recently, from the NHS and local authority, I would have to say my overwhelming experience is that we do not, and as a profession we need to do better.  

One of the key issues is no record of asking consent for therapy input, this could be for a one time intervention, for example, an on ward washing and dressing assessment or cooking session. It could be a period of time to conclude all the actions agreed with the client, for example, the assessment, provision and training of a hoist or a six-week wellbeing course. Whatever it is, record it clearly in the notes.

Ongoing notes should not be an afterthought, they should not be scribbles at the end of the day in poor handwriting, but well thought out, clear notes that provide essential information for all of our colleagues, completed in a timely manner. We must add admin time into our day to complete our clinical notes. If on a visit, keep your contemporaneous notes and scan them if necessary, to keep on client’s files, as a timely record of your observations and recommendations.

Also remember that your records can be used as part of a court case, so make sure they are full, accurate, clear, concise, legible and understandable. Only ever use recognised abbreviation agreed by your company, Trust or local authority, or better still, none at all.

Therefore, I challenge you to do three things,

  1. Ask a colleague to review your notes and do a critical evaluation
  2. Complete a reflection on your note keeping, highlighting what has worked, what doesn’t and how you can improve
  3. Ask for professional support from our governance team on how to audit your clinical notes against company, Trust, or local authority procedure.

The outcome will make you much better at writing clinical notes, making handover to colleagues easier, which will ultimately provide a better quality of service to your patient/clients.

Please do also take time to read the HCPC standards of conduct, performance and ethics and the RCOT’s record keeping document,  both of which can be recorded as continued professional development.

Column first appeared in the Nov/Dec 2020 issue of The OT Magazine.

The OT Service
The OT Service provides high quality advice, consultancy and training to manufacturers, retailers and service providers. It also provides occupational therapy clinical services in housing and equipment to case managers, solicitors and private individuals via its handpicked network of occupational therapists.

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